Anexa nr.

3 la normele metodologice
Centrul de informare i consiliere a femeilor
Privind msurile de prevenire a cancerului de
col uterin i de mobilizare a populaiei eligibile
pentru testarea Babe Papanicolau reprezentat prin
.....................................................................................
Adresa: .......................................................................
Numr contract ncheiat cu CAS: ...............................

Reprezentantul legal al furnizorului

de servicii medicale
......................................................................................
Medic de familie
......................................................................................

BORDEROU CENTRALIZATOR
pentru luna............... anul .....
_________________________________________________________________________________
|Nr.
|CNP al femeii cu
|
Data
|
Seria
|Tarif/
|Total sum |
|crt. |fomularul FS1 completat | eliberrii |formularului|caz testat |de decontat|
|
|n integralitate
|formularului|
|Babe
|
(lei)
|
|
|
|
FS1
|
|Papanicolau|
|
|
|
|
|
|
(lei)
|
|
|______|________________________|____________|____________|___________|___________|
| C0 |
C1
|
C2
|
C3
|
C4
|
C5
|
|______|________________________|____________|____________|___________|___________|
|
1 |
|
|
|
15
|
15
|
|______|________________________|____________|____________|___________|___________|
|
2 |
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
3 |
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
4 |
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|
|
|
|
|
|
|
|______|________________________|____________|____________|___________|___________|
|TOTAL:|
x
|
x
|
x
|
x
|
|
|______|________________________|____________|____________|___________|___________|

Rspundem de realitatea i exactitatea datelor.

Reprezentant legal,
.................................................
(semntura i tampila)